Failure to Supervise Residents with Known Risk Leading to Sexual Incident
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident-to-resident sexual incident involving two residents, both of whom had intact cognition and were independently mobile. One resident had a history of trauma and the other had a documented prior incident of inappropriate touching of another resident. Despite this history, both residents were allowed to visit each other unsupervised in a private room with the door closed, and staff were aware of these visits but did not monitor or check on them during these times. Multiple staff members, including nursing assistants, social workers, and the Director of Nursing, acknowledged awareness of the friendly relationship and unsupervised visits between the two residents. Staff interviews revealed that no interventions were implemented to prevent inappropriate contact during these visits, even though one resident had a known history of inappropriate sexual behavior. The facility's abuse prohibition policy defined sexual abuse as non-consensual sexual contact of any type with a resident, yet there was a lack of preventive measures in place. The incident came to light when one resident reported feeling uncomfortable and stated that the other resident had touched them in a manner they did not consent to, despite having previously had a consensual relationship. The resident reported telling the other to stop, but the inappropriate touching continued. Documentation and interviews confirmed that staff were aware of the risk factors and the unsupervised nature of the visits but failed to implement or explain any interventions to ensure resident safety during these interactions.